Question

A home health nurse is caring for a client who has chemotherapy- induced nausea that has been resistant to relief from pharmacological measures. Which of the following interventions should the nurse initiate? (Select all that apply.)

Answer 1

Correct Answers:

Maintain the head of the client's bed in an elevated position after eating.
Provide sips of room-temperature ginger ale between meals.
Assist the client in using guided imagery

Rationale :

🛏️ A. Maintain the head of the client's bed in an elevated position after eating

💥 Elevating the head of the bed post-meal helps promote gastric emptying and reduces the risk of reflux, which can trigger or worsen nausea in clients undergoing chemotherapy. 💥 Lying flat can cause stomach contents to move upward, increasing discomfort. 💥 Keeping the client upright for at least 30–60 minutes after eating is a simple and effective non-pharmacologic intervention to manage persistent nausea.

🥤 B. Provide sips of room-temperature ginger ale between meals

💥 Ginger is a well-established natural remedy for nausea and is often recommended for clients with chemo-induced nausea and vomiting (CINV). 💥 Offering it at room temperature avoids temperature extremes, which may irritate the stomach lining. 💥 Taking small sips between meals helps keep the client hydrated without overwhelming the stomach or triggering nausea with large volumes.

🧘 E. Assist the client in using guided imagery

💥 Guided imagery is a mind-body technique that helps clients manage nausea by promoting relaxation and distraction. 💥 It can be especially helpful when traditional pharmacologic interventions are insufficient. 💥 This intervention involves helping the client visualize calming scenes or experiences, which can reduce anxiety, stress, and associated nausea, improving overall quality of life.

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Answer 2

Correct Answers:

Cognitive behavioral therapy

Rationale :

🧠 Cognitive Behavioral Therapy (CBT) is a well-established, evidence-based treatment for alcohol use disorder (AUD) that focuses on modifying harmful thoughts and behaviors associated with substance use.

🧠 CBT helps clients identify triggers, develop coping strategies, and replace maladaptive behaviors with healthier responses. It is often used in both individual and group settings and is highly effective in maintaining long-term sobriety.

🧠 Unlike medications used for opioid overdose or dependency (e.g., naloxone or methadone), CBT is non-pharmacological and specifically targets behavioral change and relapse prevention in clients with alcohol-related issues.

🧠 CBT can be integrated into a comprehensive treatment plan that may also include support groups (e.g., AA), motivational interviewing, and medical management, depending on the severity of dependence.

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Answer 3

Correct Answers:

Initiate a referral for the client to a social worker

Rationale :

🤝 A social worker is specially trained to assist clients with financial, social, and community resource needs, making them the most appropriate referral when a client expresses concerns about affording groceries due to a loss of income.

🤝 The social worker can help the client access public assistance programs such as SNAP (Supplemental Nutrition Assistance Program), Meals on Wheels, or local food banks, and may assist with disability benefits or financial planning.

🤝 Rather than offering temporary or informal help (like delivering groceries), a referral to a social worker provides a sustainable, long-term solution that addresses both economic and functional challenges following the stroke.

🤝 This action also respects professional boundaries and promotes client independence, connecting the client with the appropriate multidisciplinary support system.

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Answer 4

Correct Answers:

Occupational Safety and Health Administration

Rationale :

🏭 The Occupational Safety and Health Administration (OSHA) is the federal agency responsible for ensuring safe and healthy working conditions by setting and enforcing standards and providing training, outreach, and education.

🏭 When a group of employees from the same workplace presents with symptoms such as dizziness, headache, and nausea, it suggests a possible hazardous exposure or environmental safety violation in the workplace.

🏭 OSHA is the appropriate agency to investigate workplace-related illnesses, including potential chemical exposures, carbon monoxide leaks, or poor ventilation in industrial or repair settings like automotive shops.

🏭 Prompt notification allows OSHA to conduct workplace inspections, identify the source of the problem, and enforce necessary remediation measures to prevent further incidents.

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Answer 5

Correct Answers:

Determine how the adolescent's health has affected family roles.

Rationale :

🏠 A faith community nurse provides holistic and family-centered care, which includes understanding how a chronic illness like leukemia impacts the entire family system, including changes in roles, routines, and responsibilities.

🏠 Exploring how the illness has altered family dynamics helps the nurse identify areas of stress, caregiver burden, and emotional strain, allowing for appropriate interventions and support planning.

🏠 This approach respects both the adolescent's autonomy and the family’s collective experience, fostering open communication and promoting coping and resilience in a faith-based context.

🏠 It is more effective than directing conversation only to parents, making unsupported assumptions about future plans, or introducing external parties prematurely.

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Answer 6

Correct Answers:

The children

Rationale :

🧒 In the epidemiological triangle (host–agent–environment), the host is the person or population at risk of infection. In this scenario, the children represent the host because they are the ones who have contracted or are susceptible to mumps.

🧒 The host's characteristics—such as age, immunity status, vaccination history, and overall health—affect how the disease develops and spreads.

🧒 Recognizing the host helps public health professionals target preventive measures (e.g., vaccination, health education) and early interventions during outbreaks.

🧒 The other components of the triangle include:

Agent: The virus (mumps virus).

Environment: The school, where close contact facilitates transmission.

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Answer 7

Correct Answers:

A client who reports that her new colostomy stoma appears purple

Rationale :

🔴 A purple colostomy stoma is a critical and urgent finding that may indicate compromised blood flow or ischemia. A healthy stoma should appear pink to red and moist; discoloration such as purple, blue, or black signals a medical emergency.

🔴 If left unaddressed, this condition can lead to stoma necrosis, infection, and potential sepsis. The nurse must act quickly to notify the provider and arrange for immediate assessment and intervention.

🔴 In comparison:

Vomiting after methylphenidate may be a side effect or poor absorption issue, but not immediately life-threatening.

An SpO₂ of 90% in a client with COPD can be acceptable depending on their baseline and doesn’t necessarily require urgent action.

Feeling a vibration (thrill) over a new AV graft is a positive sign indicating proper blood flow and graft patency.

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Answer 8

Correct Answers:

Analyze findings from a facility tabletop disaster simulation.

Rationale :

📊 A tabletop disaster simulation is a comprehensive, scenario-based exercise that allows staff to walk through a simulated emergency response in real time, discussing roles, actions, and decision-making.

📊 It enables administrators to identify strengths, gaps, and system vulnerabilities in the disaster plan by simulating actual response efforts in a safe, controlled environment.

📊 This method evaluates both the content of the plan and staff performance, offering a more realistic and system-wide measure of readiness compared to passive methods like quizzes or discussions.

📊 Findings from tabletop simulations provide actionable data that can be used to revise protocols, strengthen communication, and improve coordination across departments and roles.

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Answer 9

Correct Answers:

Scratching or piercing the skin

Rationale :

🚨 Scratching or piercing the skin may indicate self-harming behavior, which is a serious red flag for emotional distress, depression, or underlying mental health disorders such as anxiety or trauma.

🚨 This behavior is potentially dangerous and harmful, and may be a coping mechanism for intense emotional pain, making it the priority concern for immediate assessment and intervention.

🚨 Unlike the other behaviors—which may reflect poor coping or stress outlets—self-injury carries immediate physical risk and can escalate without proper psychological support.

🚨 The nurse should respond with sensitivity and urgency, ensuring the adolescent is assessed for safety and mental health needs, and referred to appropriate counseling or support services.

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Answer 10

Correct Answers:

Provide quiet time during visits for prayer or meditation

Rationale :

🙏 A faith community nurse integrates spiritual care with clinical support, and offering quiet time for prayer or meditation respects the client's spiritual needs, autonomy, and coping preferences during end-of-life care.

🙏 This intervention aligns with the nurse’s role in providing holistic care, which includes emotional, physical, and spiritual well-being—especially important in clients facing terminal illness.

🙏 Supporting the client’s spiritual practice can promote inner peace, reduce anxiety, and improve the client’s sense of control and dignity in the final stages of life.

🙏 This action allows the client to lead their spiritual experience, rather than making assumptions or decisions about their care or beliefs, and maintains privacy and respect.

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QLexNursing

1 :
A home health nurse is caring for a client who has chemotherapy- induced nausea that has been resistant to relief from pharmacological measures. Which of the following interventions should the nurse initiate? (Select all that apply.)

2 :
A nurse working in a community health center is providing teaching to a client who has an alcohol use disorder. Which of the following treatment methods should the nurse include in the teaching?

3 :
A home health nurse is visiting a client who has right-sided weakness following a recent stroke. The client states, "I'm not sure how I will buy my groceries since I can't go back to work." Which of the following actions should the nurse take?

4 :
A group of technicians from a local automotive repair shop presents to an urgent care clinic with reports of dizziness, headaches, and nausea. After providing needed care to the clients, which of the following government agencies should the nurse notify to follow up on these reports?

5 :
A faith community nurse is preparing to meet with the family of an adolescent who has leukemia. Which of the following actions should the nurse plan to take?

6 :
A nurse is assessing an outbreak of mumps among school-age children. Using the epidemiological triangle, the nurse should recognize that which of the following is the host?

7 :
A home health nurse is reviewing messages from a group of clients. Which of the following clients should the nurse contact first?

8 :
A nurse manager is reviewing the disaster plan at a long-term care facility. Which of the following is the most comprehensive method for the nurse to use to determine the effectiveness of the plan?

9 :
A school nurse is discussing stress management techniques with a group of adolescents. Which of the following activities reported by an adolescent should the nurse identify as the priority?

10 :
A faith community nurse is planning care for a client who has been diagnosed with end-stage breast cancer. Which of the following interventions should the nurse include in the plan?

QLexNursing

1 : A home health nurse is caring for a client who has chemotherapy- induced nausea that has been resistant to relief from pharmacological measures. Which of the following interventions should the nurse initiate? (Select all that apply.)

2 : A nurse working in a community health center is providing teaching to a client who has an alcohol use disorder. Which of the following treatment methods should the nurse include in the teaching?

3 : A home health nurse is visiting a client who has right-sided weakness following a recent stroke. The client states, "I'm not sure how I will buy my groceries since I can't go back to work." Which of the following actions should the nurse take?

4 : A group of technicians from a local automotive repair shop presents to an urgent care clinic with reports of dizziness, headaches, and nausea. After providing needed care to the clients, which of the following government agencies should the nurse notify to follow up on these reports?

5 : A faith community nurse is preparing to meet with the family of an adolescent who has leukemia. Which of the following actions should the nurse plan to take?

6 : A nurse is assessing an outbreak of mumps among school-age children. Using the epidemiological triangle, the nurse should recognize that which of the following is the host?

7 : A home health nurse is reviewing messages from a group of clients. Which of the following clients should the nurse contact first?

8 : A nurse manager is reviewing the disaster plan at a long-term care facility. Which of the following is the most comprehensive method for the nurse to use to determine the effectiveness of the plan?

9 : A school nurse is discussing stress management techniques with a group of adolescents. Which of the following activities reported by an adolescent should the nurse identify as the priority?

10 : A faith community nurse is planning care for a client who has been diagnosed with end-stage breast cancer. Which of the following interventions should the nurse include in the plan?

1 :
A home health nurse is caring for a client who has chemotherapy- induced nausea that has been resistant to relief from pharmacological measures. Which of the following interventions should the nurse initiate? (Select all that apply.)

2 :
A nurse working in a community health center is providing teaching to a client who has an alcohol use disorder. Which of the following treatment methods should the nurse include in the teaching?

3 :
A home health nurse is visiting a client who has right-sided weakness following a recent stroke. The client states, "I'm not sure how I will buy my groceries since I can't go back to work." Which of the following actions should the nurse take?

4 :
A group of technicians from a local automotive repair shop presents to an urgent care clinic with reports of dizziness, headaches, and nausea. After providing needed care to the clients, which of the following government agencies should the nurse notify to follow up on these reports?

5 :
A faith community nurse is preparing to meet with the family of an adolescent who has leukemia. Which of the following actions should the nurse plan to take?

6 :
A nurse is assessing an outbreak of mumps among school-age children. Using the epidemiological triangle, the nurse should recognize that which of the following is the host?

7 :
A home health nurse is reviewing messages from a group of clients. Which of the following clients should the nurse contact first?

8 :
A nurse manager is reviewing the disaster plan at a long-term care facility. Which of the following is the most comprehensive method for the nurse to use to determine the effectiveness of the plan?

9 :
A school nurse is discussing stress management techniques with a group of adolescents. Which of the following activities reported by an adolescent should the nurse identify as the priority?

10 :
A faith community nurse is planning care for a client who has been diagnosed with end-stage breast cancer. Which of the following interventions should the nurse include in the plan?